Social Inequalities in Breakfast Consumption Among Adolescents in Spain: the Deskcohort Project
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nutrients Article Social Inequalities in Breakfast Consumption among Adolescents in Spain: The DESKcohort Project Laura Esquius 1 , Alicia Aguilar-Martínez 1 , Marina Bosque-Prous 2,3,* , Helena González-Casals 4, Anna Bach-Faig 1 , Ester Colillas-Malet 4, Gemma Salvador 5 and Albert Espelt 3,4,6 1 Foodlab Research Group, Faculty of Health Sciences, Universitat Oberta de Catalunya, 08018 Barcelona, Spain; [email protected] (L.E.); [email protected] (A.A.-M.); [email protected] (A.B.-F.) 2 Faculty of Health Sciences, Universitat Oberta de Catalunya, 08018 Barcelona, Spain 3 Departament de Psicobiologia i Metodologia en Ciències de la Salut, Universitat Autònoma de Barcelona (UAB), 08193 Bellaterra, Spain; [email protected] 4 Department of Epidemiology and Public Health, Faculty of Health Sciences of Manresa, Universitat de Vic—Universitat Central de Catalunya (UVic-UCC), 08242 Manresa, Spain; [email protected] (H.G.-C.); [email protected] (E.C.-M.) 5 Agència de Salut Pública de Catalunya, Departament de Salut, Generalitat de Catalunya, 08005 Barcelona, Spain; [email protected] 6 Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain * Correspondence: [email protected] Abstract: Breakfast has a critical role in energy balance and dietary regulation. Consequently, it is considered an important component of a healthy diet, especially in adolescence, when there are Citation: Esquius, L.; great opportunities to consolidate habits and establish future patterns of healthiness in adulthood. Aguilar-Martínez, A.; Bosque-Prous, Socioeconomic position (SEP) causes inequalities that are reflected in health behaviors, physical M.; González-Casals, H.; Bach-Faig, activity, mental health, and diet. Therefore, we conducted a cross-sectional study using data from the A.; Colillas-Malet, E.; Salvador, G.; 2019–2020 DESKcohort project (Spain) to explore the relationships between breakfast and sociodemo- Espelt, A. Social Inequalities in Breakfast Consumption among graphic characteristics, health-related behaviors, and school performance of 7319 adolescents. Our Adolescents in Spain: The findings showed that the prevalence of skipping breakfast every day was 19.4% in girls and 13.7% in DESKcohort Project. Nutrients 2021, boys and was related to students’ SEP. The risk of skipping breakfast was 30% higher in girls from 13, 2500. https://doi.org/10.3390/ the most disadvantaged SEP, in comparison to those in the most advanced SEP (prevalence ratio nu13082500 (PR) = 1.30; 95% confidence interval (CI) = 1.11–1.54). Also, boys from the most disadvantaged SEP showed 28% higher risk of skipping breakfast than those in the most advanced SEP (PR = 1.28; 95% Academic Editor: Kalliopi Karatzi CI = 1.04–1.59). In conclusion, future public policies should be adapted considering a SEP and gender perspective to avoid increasing nutritional and health inequalities. Received: 31 May 2021 Accepted: 19 July 2021 Keywords: breakfast skipping; adolescents; socioeconomic position; social inequalities; social deter- Published: 22 July 2021 minants of health Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- 1. Introduction iations. Adolescence is an important period in life in which the opportunities for consolidating healthy lifestyles are great and future patterns of adult health are established [1]. During adolescence, individuals have increasing control over their food choices and dietary habits. In this context, families, peers, and schools play a relevant role and should be considered Copyright: © 2021 by the authors. among the determinants of health [2,3]. Adolescence is, therefore, the right vital stage to Licensee MDPI, Basel, Switzerland. develop health promotion programs aimed at influencing optimal growth and develop- This article is an open access article ment, helping to reduce the chronic diseases in adulthood and indirectly favoring adequate distributed under the terms and academic performance [4–8]. conditions of the Creative Commons Attribution (CC BY) license (https:// Socioeconomic position (SEP) refers to the social and economic factors that influence creativecommons.org/licenses/by/ what positions individuals or groups hold within the structure of a society. Such factors 4.0/). include educational level, income, and wealth. Different opportunities between people Nutrients 2021, 13, 2500. https://doi.org/10.3390/nu13082500 https://www.mdpi.com/journal/nutrients Nutrients 2021, 13, 2500 2 of 15 with a different SEP cause socioeconomic inequalities that are reflected in health [9]. In Spanish adolescents, the effects of social inequalities have been found in several diseases and health behaviors, including obesity, dental health, physical activity, mental health, and diet [10]. Breakfast, defined as the first meal of the day, has a critical role in energy balance and dietary regulation. Consequently, it is considered an important component of a healthy diet [11]. The metabolic effects of breakfast are an open question and the timing of breakfast is a relevant aspect since it is directly connected to nighttime fasting duration, which has been reported to be crucial for metabolism [12]. Currently, there is no consensus on the definition of breakfast. Such definitions vary across studies [11,13–15], either considering the time of consumption, the energy content, or the included foods and beverages. Moreover, for adolescent students in Mediterranean context, it is possible to have two eating occasions for breakfast, at home or at school. Different studies have focused on the analysis of breakfast and its quality considering any of the two eating occasions [16]. Children and adolescents who regularly consume breakfast more likely have a good diet quality [13–17]. Moreover, having breakfast has also been associated with positive ef- fects on students’ cognitive development and better school performance in children [18–21]. However, breakfast is the meal that is most often skipped by children and adolescents [22]. As previously reviewed, a 10% to 30% prevalence of skipping breakfast was identified among adolescents which increased over age [23]. Skipping breakfast has been associ- ated with female gender, later adolescence, living in single parent families, and lower socioeconomic position. Increased breakfast skipping has also been found to be positively correlated with unhealthy lifestyle, poorer diet, less physical activity, and more time spent watching television [17]. For children and adolescents, skipping meals (in particular breakfast, that stops nighttime fasting) could be a predictor of lifestyle behaviors, and it has been related to overweight, obesity, metabolic diseases [23] and it is a common eating behavior among adolescents that puts them at risk of nutrient deficiencies since it has been reported to decrease daily energy and nutrient intake [24]. As the HBSC study pointed out, there is an association between SEP and breakfast behaviors in adolescence, therefore daily breakfast consumptions should be encouraged as much as possible within the context of each country and family [17]. The main objective of this study was to estimate the prevalence of secondary-school students from Central Catalonia that regularly skip breakfast and analyze how social inequalities are related to this eating behavior. 2. Materials and Methods This study uses a cross-sectional design with data from the first wave of the DESKco- hort project [25], which was conducted between October 2019 and February 2020. The aim of the DESKcohort project was to monitor 12- to 18-year-old students that attend educational centers in Central Catalonia, collecting and analyzing data about health-related factors, and social and educational life. The 91 secondary education centers of Central Catalonia were invited to participate in the project, and 65 accepted (71%). The final study population consisted of 7319 students aged 12–18 years. During data collection, each participant responded to an online self-administered questionnaire using a tablet. This questionnaire addressed demographic, educational, and socioeconomic factors, and also health and health-related behaviors. The administration of the questionnaires by a trained person in the schools allowed clarifying concepts with the students both before and during the process. The dependent variable was “skipping breakfast every day” and was constructed on the basis of the question “How many days have you had breakfast in the last week?” [26]. It had four possible response options: none; 1–3 days; 4–6 days; every day. Skipping breakfast every day was built as a dichotomous variable (never having breakfast vs. having Nutrients 2021, 13, 2500 3 of 15 breakfast some days or every day). We considered breakfast as the first meal of the day that breaks the fasting status after the long period of sleep. It occurs within 2 to 3 h of awakening, before starting classes. Finally, it comprises food or beverage from at least one food group, and may be consumed at any location [11]. Thus, according to this definition, skipping breakfast was considered as not eating any solid or liquid food on any day of the last week [24], and thus there is a skipping of all the breakfasts. The main independent variable was the perceived SEP, which was a continuous variable adapted from the validated MacArthur Scale of Subjective Social Status [27], which has excellent test-retest reliability (intraclass correlation = 0.73). To define this